Carrying Equity in COVID-19 Vaccination Forward: Guidance Informed by Communities of Color

"As jurisdictions continue their COVID-19 vaccination campaigns, advancing equity while improving vaccine coverage will help create opportunities for durable change that will benefit everyone moving forward."

Equity in vaccination demands that the most marginalised, vulnerable individuals in a community have the same ability to access vaccination as anyone else in that community. This means that they are aware of the vaccine's purpose and availability, understand the value of vaccination, have the means to get to a point of vaccination without worry of undue risk, and are able to receive the vaccine if they choose to do so. Drawing on research conducted with Black and Hispanic/Latino communities across the United States (US), this report from the CommuniVax Coalition provides guidance on adapting COVID-19 vaccination efforts to achieve greater vaccine coverage in underserved populations and, through this, to develop sustainable, locally appropriate mechanisms to advance equity in health.

The research driving this report was derived from the efforts of local teams working with Black and Hispanic/Latino communities in 6 distinct US sites, beginning in January 2021. Building on their existing relationships in these communities, the teams: used rapid ethnographic methods, including interviews, focus groups, and social mapping, to listen to community members, public health officials, and government leaders; completed an environmental scan to assess community infrastructure; and coordinated community engagement activities (e.g., town halls, human-centred design workshops) to understand how best to promote awareness of, access to, and acceptability of COVID-19 vaccines.

The main findings, as presented in the first part of the report, are:

• Myopically focusing on "vaccine hesitancy" as the problem obscures a more complex set of realities - Vaccine decision making is ongoing, dynamic, and social, rather than a straightforward process of an individual, alone, digesting educational materials and then moving to action. For example, the same socioeconomic and structural forces (e.g., economic and racial inequalities) that contribute to the disparate impacts of COVID-19 have also created persistent barriers to accessing vaccines. In the words of Monica Schoch-Spana (interview linked in the Source section, below): "These are practical hurdles that require reconfiguring vaccine delivery and communication strategies, rather than overcoming perceived deficits in a person's feelings, thinking, or even moral fiber." In considering barriers that can prevent individuals from receiving COVID-19 vaccines, it is important to recognise that many people face multiple barriers simultaneously.
• Assuming communities of colour are homogeneous is a mistake - Despite some similarities, differences between and within local communities make them unique and result in different experiences. Black and Hispanic/Latino persons experience racism differently due to factors such as language, culture, and historical experiences with certain institutions (e.g., immigration and law enforcement). Within communities, demographic characteristics like age, gender, and political party affiliation influence individuals' perspectives.
• Hyperlocal responses to the pandemic result in better health outcomes - Remaining pockets of hesitancy and issues of access are now best addressed at local levels, where experiences with COVID-19, concerns about COVID-19 vaccines, and the impact of socioeconomic and cultural variables can be properly understood and acted upon in context using locally feasible solutions from trusted sources. Grassroots groups already have the trust of community members and understand the socioeconomic and cultural realities of their lives; without trust, education campaigns, national messaging campaigns, and other pro-vaccination efforts fall flat. Examples of community-led, -organised, and -advocated measures that have closed COVID-19 response gaps are provided in the report.

Drawing from these insights and looking ahead, the authors recommend 2 differently paced streams of activity for local, state, and federal officials, with the theme of community trust linking them together:

Urgent actions to be taken immediately to improve vaccine coverage within underserved communities:

• Humanise delivery and communication strategies for COVID-19 vaccines - Support more peer-led and neighbourhood-based opportunities for community conversation and for convenient vaccine access. Health systems and health departments should develop and/or strengthen their collaborations with community-based organisations (CBOs), faith-based organisations (FBOs), and community health workers (CHWs), letting them take the lead in diagnosing low vaccine coverage and developing interventions. Examples include prompting peer-to-peer conversations via culturally relevant, multilingual vaccine communications that involve as many social settings as possible in person, on air, and on screen. Vaccination campaign organisers should commit to maintaining relationships with these groups (CBOs, FBOs, and CHWs) after the COVID-19 pandemic subsides.
• Anchor COVID-19 vaccination for hard-hit areas in a holistic recovery process:
  1. Public agencies, hospitals and health systems, nonprofit social service providers, CBOs, FBOs, and CHWs should align themselves around a "whole person" model of recovery to meet underserved communities' self-identified needs (eg, food, housing, jobs, mental health support) and to multiply the benefits of each vaccination encounter.
  2. Local and state jurisdictions should take immediate steps to plan for long-term recovery and community resilience by: (a) convening a cross-sector council of stakeholders, including Black and Hispanic/Latino leaders, CBOs, FBOs, and CHWs; and (b) engaging existing data-driven coordinating bodies that already facilitate disaster recovery, economic development, and other long-range planning.

Essential actions to execute steadily in order to create systems-level changes and advance health equity broadly:

• Develop a national immunisation programme to protect people throughout the life course - Tasks include reconfiguring funding systems to support a life-course (versus childhood-only) approach to immunisation, facilitating the integration of adult immunisation with other health systems and priorities, and developing systems to monitor programme progress and measure social and economic impacts.
• Rebuild the public health infrastructure, properly staffing it for community engagement - For example, state and local health departments should commit to the strategic goals of promoting equity in their ranks at every level, including their boards of health, and strengthening human-centric competencies through the recruitment of more social and community proficient professionals, such as health educators/promoters, risk communicators, language translators, social media strategists, and socio-behavioural researchers.
• Stabilise the community health system as the backbone for equity and resilience - Through community roots and shared experiences, CHWs: build trust with clients while navigating health and human services systems, bridge client and provider cultures to adapt service delivery and better meet needs, and advocate for system-level changes that will improve clients' access to care and overall health. Thus, in consultation with local, regional, and national CHW networks, federal and state officials should create sustainable financing strategies for community health work on disease prevention, health promotion, and social determinants of health.

In conclusion: "The country needs to seize this moment to achieve widespread and lasting COVID-19 vaccine coverage, including among the most vulnerable groups, and to develop locally appropriate mechanisms that advance equity in health."